2020 Physician Fee Schedule

Proposed changes likely to shift financial resources from specialist services to primary care

THE MEDICARE Physician Fee Schedule for 2020, which was posted on the Federal Register July 29 for comment, includes changes “aimed at reducing burden, recognizing clinicians for the time they spend with patients, removing unnecessary measures, and making it easier for them to be on the path towards value-based care,” according to a Centers for Medicare and Medicaid Services press release. The federal CMS projects the proposed rule will “save 2.3 million hours per year in burden reduction.”

Remote Patient Monitoring
The proposal contains, among many other items, two changes applicable to remote patient monitoring (RPM) services eligible for Medicare reimbursement. Under the proposed rule, RPM services may be delivered under general supervision, and a new addon code was proposed for patients who receive more than 20 minutes per month of RPM services. These new developments are intended to continue expanding digital healthcare and to provide clarity for RPM codes that were created at the beginning of 2019. The federal CMS will accept comments on the 2020 Physician Fee Schedule until Sept. 27, 2019.

Evaluation and Management
The proposed rule also aims to build on changes CMS finalized last year to streamline billing for evaluation and management (E/M) visit codes. In last year’s proposed rule, the agency suggested collapsing the five-tier payment system for E/M visits— a move that drew pushback from physician groups who worried the changes could lead to unintended consequences. Both the Chicago Medical Society and the American Medical Association advocated against that move. In response, the agency maintained a separate level 5 code in 2019, accounting for care provided to the most complex patients.

Under the proposed rule for 2020, the agency moved back to the five-tier system for established patients and suggested moving to a four-tier coding system for new patients. The agency suggested adapting the revised E/M code definitions developed by the American Medical Association’s CPT Editorial Panel beginning Jan. 1, 2021. These CPT code changes would revise the time and decision-making guidelines for each level, and they would require documentation of patient history and a medical exam only when clinically appropriate. They would allow physicians to select the appropriate level of visit based on the extent of decision-making in the exam or based on time spent with the patient.

The federal CMS also proposed adopting the AMA’s RUC-recommended payment rates, which were set after a survey of over 50 specialty types showed that “office/outpatient E/M visits are generally more complex and require additional resources for most clinicians.” With this change, the agency would not pay a single blended rate for code level 2 through 4, but instead would make payments based on each level of service.

Under last year’s final rule, the federal CMS also implemented a new “extended visit” code that allowed physicians to receive higher payment rates for spending additional time with patients whose visits are coded at level 2 through 4.

Transitional Care Management
In an effort to ensure proper follow-up and continuity of care for patients, the federal CMS has proposed increasing Medicare transitional care management payments to recognize clinicians for the time spent managing a patient’s care after the patient leaves the hospital. The agency for the first time is proposing to pay clinicians for care management services for patients who have a single high-risk medical condition, such as diabetes or high blood pressure. It is also proposing to pay clinicians for time spent on care management activities for patients with multiple chronic conditions.

Surgery Follow-ups
The federal CMS generally followed the RUC’s recommendations, but there were two notable exceptions, according to the AMA

One is that primary care and other physicians will get an add-on payment for office visits by patients to whom they provide ongoing primary care or who have at least one serious or complex condition. By law, any changes to the payment schedule’s RVUs must be budget neutral. The add-on payment will be paid for by redistributing up to $2 billion from Medicare’s conversion factor and other physician services. The second is that while payment will rise for stand-alone office visits in 2021, the visits bundled into the global surgery package will not be increased. CMS has historically increased these bundled visits to be equivalent to the valuation of stand-alone office visits.

Specialties whose practices rarely have office visits with patients are set to see cuts in 2021. For 2020, a small pay increase for most physicians is expected as the proposed conversion factor is $36.0896, or 5 cents higher per RVU, than it is for 2019

. Concerns about the projected 2021 pay cuts for surgeons and other physicians will be included in the AMA’s comments on the proposed payment schedule. Comments are due by Sept. 27. By statute, the final Medicare physician fee schedule must be released on or before Nov. 1.